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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />13 TANK RETROFIT C1 PIPING REPAIR/RETROFIT /UDC REPAIR/RETROFIT /COLD START/EVR UPGRADE <br />F <br />EPA Site # Contact & Telephone # A,1.f a�, tiLlNil f raw -.7% <br />_ <br />_Project <br />Phone # <br />Facility Name - ` r ctt'. �% Sl%s - <br />�. <br />Address �p-^�_S,�_�l.s_..�%fEs� �1T ;R Cir VGj< <br />TGross <br />Street L," <br />Y <br />Owner/Operatot'T-i S-, V,V.NV_j&.. IL "4hUz4Z4-(A k GO. .hone #„?,i0 -gj ZG_6ZZZ, <br />o <br />Contractor Name 5� S prS�, Phone # '� ;2411-17_ 7!!;- <br />T <br />Contractor Address IS{mss rAT,„ SLEAQot�3 <br />CALic# �`tS"j, ,2�' Class Q4f�r�j�� <br />A <br />Insurer y,. -o yr vt�y4 <br />Wdrk Comp # ci ,7SS^Y ['Z <br />T <br />ICC Technician's Name )_b <br />Expiration Date q (�t2x3 13 <br />RICC <br />Installer's Name 'ZD%Ar „S <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently <br />(i -e. 87 piping sump, 91 leak detector, UDC 1/2, etc-) <br />Date UST <br />Installed <br />T <br />A <br />17! t,Vme.-i colt <br />N <br />K <br />r-t"4T I ryV VA_ i> SrQj.s <br />p <br />t N�'S'P 1A- r'-W%A) g F ti N <br />P <br />L <br />A <br />I- Approved 1 Approved with conditions �....� Disapproved <br />(Se Attachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK W ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH TWS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIF05NIIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA-" <br />/ SS /` ✓ _2 Ll <br />Applicant's Si4nature ..... _ ...._Title /�'1C"Jt Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />t <br />SIGNATURE <br />EH230038 (revised 08/1/115 <br />TITLE �{-1`-"'� PHONE# S!r��-,�' 3c <br />DATE f>--/ t LIV <br />2 <br />i 3au <br />9-2 <br />